What exercise instruction should the nurse include when teaching a client with heart failure?
Answer:
Walk three times per week and gradually increase duration.
Rationale:
Regular activity improves circulation, cardiac conditioning, and blood pressure control.
What is the normal serum calcium level?
Answer:
9.0–10.5 mg/dL.
Rationale:
This is the normal range needed for muscle contraction, nerve function, and cardiac activity.
Which assessment finding is most consistent with COPD?
Answer:
Barrel chest.
Rationale:
Chronic air trapping causes increased AP diameter.
Which electrolyte imbalance is commonly seen with acute kidney injury?
Answer:
Hyperkalemia.
Rationale:
The kidneys cannot excrete potassium effectively.
Which diagnostic test is contraindicated in most patients with a pacemaker?
Answer:
MRI.
Rationale:
The magnetic field can interfere with pacemaker function.
Which finding is associated with left-sided heart failure?
Crackles and dyspnea.
Rationale:
Left ventricular failure causes blood to back up into the lungs, leading to pulmonary congestion.
Which finding suggests hypercalcemia?
Answer:
Confusion and lethargy.
Rationale:
Excess calcium slows neuromuscular activity.
What abnormal lung sound is described as a grating, leathery sound?
Answer:
Pleural friction rub.
Rationale:
Inflamed pleural surfaces rub together during respiration.
Which foods are high in potassium?
Answer:
Bananas, yogurt, and orange juice.
Rationale:
These foods can worsen hyperkalemia.
What does the P wave represent?
Answer:
Atrial depolarization.
Rationale:
Electrical activity moves through the atria before ventricular contraction.
Why do clients with left-sided heart failure develop crackles?
Fluid backs up into the lungs.
Rationale:
The left ventricle cannot effectively pump blood forward, causing pulmonary edema.
Which assessment finding indicates hypocalcemia?
Answer:
Tingling around the mouth.
Rationale:
Low calcium increases neuromuscular excitability.
What diet is best for a client with emphysema?
Answer:
High-calorie, high-protein diet with small frequent meals.
Rationale:
The work of breathing increases caloric needs.
Which foods are low in potassium?
Answer:
Butter, poultry, and frozen vegetables.
Rationale:
These are safer choices for patients with renal disease.
What does the QRS complex represent?
Answer:
Ventricular depolarization.
Rationale:
This represents ventricular contraction.
Name two interventions for a client experiencing left-sided heart failure.
Answer:
Administer oxygen and diuretics.
Rationale:
Oxygen improves oxygenation, and diuretics decrease fluid overload
Name two signs of hypocalcemia.
Answer:
Tetany, muscle cramps, tremors, Chvostek's sign, Trousseau's sign.
Rationale:
Low calcium causes nerves and muscles to become more excitable.
Name three symptoms of COPD.
Answer:
Dyspnea, chronic cough, sputum production, barrel chest, pursed-lip breathing.
Rationale:
Airway obstruction and hyperinflation cause these symptoms.
Why is hyperkalemia dangerous?
Answer:
It can cause life-threatening dysrhythmias.
Rationale:
High potassium affects cardiac conduction.
What does the T wave represent?
Answer:
Ventricular repolarization.
Rationale:
The ventricles are recovering and preparing for the next beat.
A patient has dyspnea, orthopnea, and crackles. What condition is occurring?
Left-sided heart failure.
Rationale:
These are classic manifestations of pulmonary congestion caused by left ventricular failure.
Name two interventions for hypercalcemia.
Answer:
IV fluids and loop diuretics.
Rationale:
Hydration and diuretics increase calcium excretion.
Why are small frequent meals recommended for emphysema patients?
Answer:
Large meals increase fatigue and worsen shortness of breath.
Rationale:
Smaller meals require less energy and reduce pressure on the diaphragm.
A patient with AKI develops a potassium level of 6.8 mEq/L. What should the nurse do first?
Answer:
Obtain an ECG.
Rationale:
Hyperkalemia can rapidly cause fatal arrhythmias.
A patient with AKI has:
What is the priority nursing action?
Answer:
Obtain an ECG and assess for dysrhythmias.
Rationale:
Hyperkalemia poses the greatest immediate threat because it can cause fatal cardiac arrhythmias.